African American and Hispanic senior citizens who lack prescription drug
benefits are three times more likely than white seniors to cut back on taking
their medications, according to a study from researchers at San Francisco
Veterans Affairs Medical Center. Although income level and medication cost
also influenced decisions to restrict medication, ethnicity was an independent
risk factor, the researchers said.
The researchers had no definitive explanation for their findings, saying that
more research is needed to explain why minority patients who lack insurance are
more likely to cut back on their prescription coverage. However, they said the
study shows that money is not the only factor that affects whether uninsured
seniors take their prescription drugs.
“Forgoing medications for lack of coverage is a very real phenomenon. This
study calls attention to the magnitude of this problem, particularly among
certain disadvantaged communities,” said Michael Steinman, MD, a fellow in the
VA National Quality Scholars Program at SFVAMC and University of California,
Seniors without prescription drug coverage were an oft-debated campaign issue
during the presidential election last fall; both major candidates offering a
different plan to add drug coverage to the Medicare benefit program.
But until now the scope of this problem had not been rigorously studied,
Steinman said. “This is the only paper we’re aware of that analyzes the scope
of this problem in detail,” he said.
The researchers surveyed 4,900 people over age 70, asking them, “at any time in
the last two years have you ended up taking less medication than was prescribed
for you because of cost?” They asked about income, assets, insurance coverage,
monthly prescription drug costs, and ethnicity.
Eight percent of seniors without coverage said they had cut back on their
medication, which represents more than one million Americans doing without
their prescribed drugs. The factors most clearly associated with a senior
taking less of their medications were low income, high out-of-pocket costs for
prescription drugs, and African-American or Hispanic ethnicity.
Nearly 21 percent of African-Americans and Hispanics reported that they had
restricted their medications, and for some groups in the study, the risks
appear to be even higher, Steinman said. “Our data suggests that among
minority seniors with low income and high drug costs, as many as 43 percent of
people without coverage could be restricting their medication,” he said.
Even when the researchers statistically adjusted for the influences of low
income, and the high monthly price tag of medications, African-Americans and
Hispanics still were three times as likely to have cut back on their
medications as white people surveyed, the researchers found.
These findings were quite surprising, Steinman said. “We can only guess why
African-Americans and Hispanics would be more likely to restrict their
medications,” he said. “It could be that attitudes about resource allocation
may be different for different ethnicities.”
“If you have a limited amount of money each month, and you have to pay for
medicine, food, telephone service, and rent from that, then in some cases not
taking your medications is an understandable choice,” Steinman said.
Rather than focus on the effect of ethnicity, Steinman hopes the study will
emphasize the sheer numbers of people forced to make these difficult financial
choices. “The point is, no one should be forced to make these choices,” he
The study did not measure the effect of skipping medications on survival or
other outcomes, but Steinman pointed out that there are risks with either
decision. “Even if choosing the medications might help them to do better in
terms of their survival, they may be suffering in other ways, for instance from
not having a telephone or proper nutrition,” he said.
A Medicare prescription drug benefit is likely to reduce the numbers of those
going without their medications, Steinman argued. However, “plans that focus
only on the poorest of the poor may to little to help other vulnerable groups.
We’re learning that this kind of approach will still leave far too many people
out in the cold,” he said.
Co-authors on the study included Laura Sands, PhD, UCSF assistant professor of
medicine, and Kenneth Covinsky, MD, MPH, staff physician at SFVAMC and UCSF
assistant professor of medicine.
Michael Steinman was supported in part by the VA National Quality Scholars